A. The Insurance Commissioner may refuse to issue or renew or may suspend or revoke a certificate if the holder does not comply with performance assurances under this section, violates any provision of the Hospital and Medical Services Utilization Review Act, or violates any rule adopted pursuant thereto.
B. The Commissioner shall deny or refuse to renew a certificate to any applicant if, upon review of the application, the Commissioner finds that the applicant proposing to conduct utilization review does not:
1. Have available the services of a sufficient number of qualified medical professionals supervised by appropriate health care providers to carry out the applicant's utilization review activities. Said sufficiency shall be based on standards and criteria pursuant to the provisions of subparagraph b of paragraph 1 of Section 8 of this act;
2. Meet any applicable rules the Commissioner adopted pursuant to the Hospital and Medical Services Utilization Review Act relating to the qualifications of private review agents or the performance of utilization review; and
3. Provide assurances satisfactory to the Commissioner that:
a.the procedure and policies of the private review agent shall protect the confidentiality of medical records, and
b.the review agent shall be reasonably accessible in this state to patients, hospitals and health care providers as required by this act.
C. Before denying, not renewing, or revoking a certificate, the Commissioner shall provide the applicant or certificate holder with reasonable time to supply additional information demonstrating compliance with the requirements of the Hospital and Medical Services Utilization Review Act and the opportunity to request a hearing. If an applicant or certificate holder requests a hearing, the Commissioner shall send a hearing notice and conduct a hearing in accordance with the Administrative Procedures Act.
D. Any person aggrieved by a final decision of the Commissioner in a contested case may appeal the decision as provided for in the Administrative Procedures Act.
Added by Laws 1991, c. 294, § 11, eff. Nov. 1, 1991.
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